Paediatric Pearls

This service, for parents who are anxious about their relationship with their baby and/or child under 3, resides within North East London NHS Foundation Trust and serves Redbridge, Waltham Forest, Barking and Dagenham and Havering communities.

The PPIMHS teams are made up of psychiatrists, community mental health practitioners and psychotherapists/psychologists and they accept referrals from Health Visitors, GPs, midwives, Children’s Centres workers or other health professionals.  Click here for their referral form.  They may signpost elsewhere after the initial consultation if appropriate or they will offer the parent/carer and infant/child 9-12 sessions to work on the parent-infant relationship.

Groups particularly at risk of having problems with bonding include families with ex-premature babies who have spent a significant amount of time on the Special Care Baby Unit, those where the baby has feeding issues or is difficult to soothe, those where breastfeeding failed to establish and those where there was a traumatic birth or difficult conception and/or pregnancy.  Many of the parents on their case load have a personal history of disturbed attachments and are keen not to let history repeat itself.  A recent audit showed that 41% of their mothers had some sort of mental health diagnosis which means that 59% did not.  Click here for an information leaflet about their service that you might like to give to your patients.

Mums with postnatal depression or post-partum psychosis should be referred directly to a perinatal psychiatrist rather than PPIMHS.  Parents struggling with a crying baby or fussy toddler but with no bonding issues should be referred to their health visitor.  The PPIMHS team is a tier 3 (specialised) service concentrating primarily on the parent-infant relationship.

Symptoms in the baby that might suggest a bonding problem:

extreme clingy behaviours, fussy, difficult to soothe, abnormal self-soothing behaviours (eg. head-banging, hair-pulling, scratching), excessive sleep problems, extreme feeding problems, lack of verbal and non-verbal communication, stiff or floppy posture, extreme fearfulness or watchfulness, lack of interest in the world, no comfort sought from parents, avoids eye contact with parents, smiles very little.

Symptoms in the parent:

high anxiety and panic about the baby, excessive A and E or GP presentations, feeling frightened of harming the baby, lack of separation between parent and baby, baby never put down, excessive sterilising of bottles and toys, detached feelings about the baby, no pride in their development, anger about baby as if baby intends to upset the parent, feelings of failure as a parent, inability to cope.

There is some evidence around this issue and around maternal stress during pregnancy and the effect of high maternal cortisol levels on the foetus’ developing brain.  I have asked the Waltham Forest PPIMHS psychologists to write a bit about that and correct anything I have written about their service!

This is the first time in ages I’ve managed to get the finalised version on line in time for the end of the month!  NICE on autism this month, a bit on the use of corticosteroids in croup with help from the Cochrane Library, update on secondary prevention of meningococcal disease and a pointer to our local educational psychologist service which is hoping to make stronger links with the borough’s GPs (see also below).  Our feeding series continues with an article on colic from one of the junior paediatricians with lots of useful links and updates.

Our local educational psychologists are running drop in sessions on the 3rd Wednesday of every month at their base in Leyton, E10.  The current flyer which includes contact details is here and sessions will be on-going in 2012 even if not listed here.  They tell me that they would be happy to run EP drop in sessions or parent workshops/training/support groups  at local GP surgeries and jointly with GPs or other medical colleagues  – GPs are welcome to contact them to discuss.  Their Urdu speaking colleague runs sessions in a local Mosque as well.

NICE has recently reviewed its guideline on depression in children and young people – an important diagnosis to be aware of when treating children in the ED.  We have also looked at the evidence around non-sedating antihistamines and found you a “how to do it” video on pulled elbows, and indeed one on umbilical hernia repair in an adult!  Umbilical hernias are common and benign, inguinal hernias may not be.  Read all about it here!

The April 2011 version is now published.   I have covered the recently reviewed NICE guideline on depression in children and young people.  We continue with the 6 week check series with some information on umbilical hernias and granulomas.  And, now that the hay fever season is upon us, we have had a look at the literature on non-sedating antihistamines.

GP February 2011 reminds us all of the NICE guideline on Attention Deficit and Hyperactivity Disorder. We continue our 6-8 week baby check series with information on the absent red reflex and go back to our “from the literature” box to discuss snoring and obstructive sleep apnoea (OSA). We have relaunched our prolonged jaundice guideline. Please leave comments and questions below.

This month’s emergency department version of Paediatric Pearls has information on the NICE guideline on ADHD, normal paediatric observations, the updated resuscitation guidelines and a bit from the literature on children who snore.  Do leave comments and questions.

I featured the 2008 NICE guideline on ADHD in the February 2011 GP version of the Paediatric Pearls newsletter.  All parents of children who are being assessed for possible ADHD should be given information about local parent training/education programmes, not to insinuate that they are poor parents but in recognition of the fact that parenting skills need to be fully optimised to meet the above average parenting needs for this group of children.  Try http://www.walthamforestclass.gov.uk/familylearning/fm.aspx#parenting  for information on lots of free parenting classes provided by Waltham Forest.

Locally, ADHD is dealt with by the Child and Family Consultation Service and all referrals should go to the child psychiatrists and psychologists there please.

School refusal is often a symptom of an underlying anxiety disorder.  The child may get anxious on separating from their primary caregiver and this manifests itself in different ways depending on the age of the child as much as anything.  There are 2 peak age groups who develop school refusal, 5-7 year olds and 11-14 year olds.  25% of school children refuse to attend school at some point in their school career but it becomes a routine problem in about 2% and the longer it goes on, the harder it is to reverse.  It is not the same as truancy.  It is not a mental illness in itself but many children who feel unable to attend school over a long period do have an underlying mental health issue.  Unfortunately funding for CAMHS is being eroded and  it is difficult to find good, and timely, help for school refusers.  The websites I have listed in December 2010 Paediatric Pearls for GPs may help give parents pointers for why it is happening and how to set about managing it.

December’s Paediatric Pearls (GP edition) reminds us all of the NICE guideline on antibiotic prescribing in respiratory tract infections.  I would like to do a bit more of the “delayed prescribing” in the Emergency Department but it would require either the family coming back (ie. a “no antibiotic” policy really) or their putting a bottle of amoxicillin in their fridge and potentially not using it as we give out the actual antibiotic in A and E, not prescriptions.  We’ve also featured a couple of papers showing that chest x-rays add very little to the management of a child with a respiratory illness which I think most GPs know but it doesn’t harm to remind trainees still in the hospital that, just because the radiology department is at the end of the corridor, it doesn’t mean you have to use it!  We continue our 6-8 week baby check series with information on sacral dimples and I have also put in a couple of websites with sensible, empathetic information and advice on school refusal.  The beginning of term is stressful for children who find it hard to go to school and parents may find these sites helpful when trying to understand why their child is behaving in that way.  Happy New Year to you all!